Arrhythmogenic effects of theophylline in human atrial tissue

Multifocal atrial tachycardia and Ibutilide

Multifocal atrial tachycardia is an electrocardiographic phenomenon seen primarily in the elderly. The hemodynamic consequences of multifocal atrial tachycardia in an elderly woman are presented. Successful treatment with Ibutilide is demonstrated. Treatment with a class III antiarrhythmic agent opposes the frequently accepted mechanism of triggered activity in causing this arrhythmia.

Radiofrequency catheter ablation of atrial fibrillation initiated by pulmonary vein ectopic beats

Ectopic beats from the pulmonary veins (PVs) have been demonstrated to initiate atrial fibrillation (AF). This article describes the conceptual approach to mapping, interpretation of different electrograms, and ablation of AF initiated by PV ectopic beats.

Multifocal atrial tachycardia

Multifocal atrial tachycardia is typically seen in elderly patients with severe illnesses, most commonly COPD. The mechanism of the arrhythmia may be delayed afterdepolarizations leading to triggered activity, but this has not been firmly established. The initial treatment of multifocal atrial tachycardia should include supportive measures and aggressive reversal of precipitating causes. Since multifocal atrial tachycardia is commonly a secondary phenomenon, the role for antiarrhythmic therapy is unclear. Metoprolol, magnesium, and verapamil have been evaluated in a few treatment studies, and may have a role in the treatment of multifocal atrial tachycardia.

Electromechanical effects of caffeine in failing human ventricular myocardium

We studied, using standard microelectrode technique, the effects of caffeine alone and in conjunction with epinephrine in ventricular myocardial fibers obtained from the failing hearts of 12 recipients of heart transplant. Results revealed that caffeine (1-3 mM) prolonged slightly the duration of fast response action potential near final repolarization and the twitch curve but slightly increased, or even decreased, the twitch force. Epinephrine (3 microM) induced a submaximal positive inotropic effect in myocardial fibers obtained from the failing hearts. Caffeine at 1 mM significantly potentiated the force of contraction and accelerated the rate of twitch relaxation increased by epinephrine. Increasing concentration of caffeine to 3 mM in the presence of epinephrine did not enhance further the twitch force but rather induced the delayed after-depolarization in two of eight experiments. In a preparation from one patient with dilated cardiomyopathy, the combination of caffeine and epinephrine induced repetitive triggered rhythms. The present findings suggest that, in human ventricular myocardium obtained from certain patients transplanted for congestive heart failure, caffeine could induce positive inotropy and triggered automaticity through a potentiation of the actions of catecholamines.

Recognition and treatment of multifocal atrial tachycardia: a critical review

Multifocal atrial tachycardia (MAT) is an uncommon but clinically important tachydysrhythmia that is usually seen in the setting of severe cardiopulmonary illness. Diagnostic criteria include the presence of at least three different, nonsinus P waves in the same lead; an atrial rate greater than 100 beats per minute; and an isoelectric baseline between P waves. MAT is often difficult to differentiate from atrial fibrillation. The pathogenesis of MAT is unknown; however, it is probably incited by "triggered" electrical activity, a form of abnormal automaticity. This electrophysiologic model has led to several small, uncontrolled clinical trials using calcium channel and beta-adrenergic blocking agents, specifically verapamil and metropolol. None of these trials meets rigorous methodologic standards, and all exclude unstable patients who are at greatest risk for hemodynamic compromise from the tachycardia. Treatment of MAT should first be directed at potential predisposing factors, such as hypoxia, congestive heart failure, and theophylline toxicity. Pharmacologic treatment includes intravenous metoprolol or verapamil; in published reports both agents have been well tolerated and have controlled the heart rate in a majority of patients.

Depressant Effects of Prostacyclin in Human Atrial Fibers and Cardiomyocytes

The aim of this study was to characterize the electropharmacological effects of prostacyclin (PGI(2)) in human atrial fibers and cardiomyocytes. Atrial tissues obtained from the hearts of 28 patients undergoing corrective cardiac surgery were used. Transmembrane action potentials were recorded using a conventional microelectrode technique, and twitch force by a transducer. Effects of PGI(2) (1 nM-10 &mgr;M) on action potential characteristics and contraction of atrial fibers were evaluated in normal [K](o) (4 mM) and high [K](o) (27 mM) in the absence and presence of cardiotonic agents. In addition, atrial and ventricular myocytes were isolated enzymatically from atrial tissues and hearts of 4 patients undergoing cardiac transplant. The effects of PGI(2) on Na- and Ca-dependent inward currents (I(Na) and I(Ca)) of cardiomyocytes were tested. In 9 human atrial fibers showing fast-response action potentials (mean dV/dt(max) = 101 +/- 15 Vs(-1)) in 4 mM [K](o), PGI(2) did not influence dV/dt(max) of phase 0 depolarization even at 1 &mgr;M. However, at a concentration as low as 10 nM, PGI(2) depressed spontaneous rhythms or slow-response action potentials in high-K-depolarized fibers. PGI(2) also depressed delayed afterdepolarizations and aftercontractions induced by cardiotonic agents. In isolated cardiomyocytes, PGI(2) reduced I(Ca) but not I(Na). The present findings show that, in human atrial fibers and cardiomyocytes, PGI(2) induces greater depressant effects on the slow-response action potential, I(Ca) and triggered activity than on the fast-response action potential. It is suggested that PGI(2) may act through a selective reduction of transmembrane Ca influx. Copyright 1994 S. Karger AG, Basel

The role of cyclic AMP and phosphodiesterase activity in the mechanism of action of tetramethylpyrazine on human and dog cardiac and dog coronary arterial tissues

The aim of the present experiments was to explore the underlying cellular mechanisms responsible for the actions of tetramethylpyrazine (TMP) on atrial, ventricular and coronary arterial tissues. Transmembrane potentials of cardiac tissues were detected by means of the glass microelectrode technique and contractile tension by a force transducer. Tissue cyclic (c) AMP level was determined by protein binding assay. Results show that in human atrial and dog Purkinje fibres, high concentration of TMP (3 mM) induced a persistent positive inotropic effect only in the presence of adrenaline. Also, 3 mM TMP increased the cAMP level of the atrial muscle fibres, especially in the presence of adrenaline. Determination of the activity of cAMP-phosphodiesterase revealed that 0.3 and 3 mM TMP inhibited the phosphodiesterase activity of dog coronary artery and human atrial tissues in a concentration-dependent manner. When compared at the lower concentration (0.3 mM), the inhibitory effect of TMP was about 60% that of theophylline. The above findings indicate that the cardiovascular effects of TMP are related to the inhibition of phosphodiesterase activity and the subsequent elevation of the cAMP concentration.

Cardiac arrhythmias during theophylline toxicity. A prospective continuous electrocardiographic study

To examine the effects of theophylline toxicity on cardiac rhythm, patients underwent continuous ambulatory ECG recording during acute theophylline toxicity and recovery. The patients, who were recruited form inpatient wards, intensive care units, and emergency departments of a University Medical Center and a Veterans Administration Medical Center, had serum theophylline concentrations (STC) greater than 30 mg/L. There were 14 men and two women with a mean age of 66 years. Fourteen patients had COPD and developed toxicity following long-term theophylline overmedication. Two patients had asthma and ingested an intentional overdose. The STC at the onset of ECG recording ranged from 23 to 67 mg/L. The principal rhythm was sinus in 15 patients; one patient had atrial fibrillation. Sinus tachycardia (heart rate greater than 100/min) was common, and heart rate fell in proportion to STC as toxicity resolved. Supraventricular ectopic beats (SVEs) were noted in seven patients with multiple runs of SVE being present in four. One patient developed multifocal atrial tachycardia (MAT) during toxicity that resolved spontaneously. During the 11 +/- 8 hours of recording during toxicity (STC greater than 20 mg/L), 80 percent of patients had ventricular premature beats (VPBs), 44 percent had paired VPBs, and 25 percent had ventricular runs. One elderly patient with heart disease developed sustained ventricular tachycardia (VT) when STC = 66 mg/L. No other patient had ventricular ectopy that required intervention. During the 10 +/- 6 hours of recording during the "recovery phase" (STC less than 20 mg/L), all patients with VPBs continued to have ectopy; however, the number of VPBs declined significantly. A follow-up 24-hour ECG recording obtained one week after recovery from toxicity in the patient with sustained VT demonstrated marked reduction in the frequency and complexity of VPBs. Patients with frequent (greater than 10/h) or repetitive VPBs were older (p less than 0.05) than those without complex ectopy. There was a trend (p = 0.07) suggesting patients with underlying heart disease were at risk for having complex ventricular ectopy. We conclude that sinus tachycardia, SVE, and VPBs are common among patients with theophylline toxicity; however, sustained ventricular or supraventricular tachyarrhythmias that require antiarrhythmic therapy are uncommon.

The assessment and treatment of theophylline poisoning

Theophylline poisoning long has been recognized as difficult to treat and still has an over-all mortality rate of about 10%. In recent years, the increasing use of sustained-release preparations has changed the pattern of toxicity. The management of theophylline toxicity is compounded by clinical differences between chronic (overmedication) intoxication and acute single ingestions of a large amount of the drug, inter- and intraindividual variability in theophylline metabolism and dose-dependent kinetics in poisoned patients. Management decisions should be based on both clinical assessment and laboratory information (particularly theophylline concentrations).

Pacemaker activity is modulated by tissue levels of cyclic adenosine 3',5'-monophosphate in human atrial fibers

We studied the role of tissue cyclic AMP levels in the chronotropic effects of theophylline on automatic human atrial fibers obtained from the hearts of 17 patients undergoing corrective open-heart surgery. Atrial fibers were perfused with Tyrode solution and transmembrane action potentials were recorded with a conventional microelectrode technique. In normal Tyrode solution, theophylline (0.1-1 mM) often decreased the late diastolic slope and the spontaneous rate. In the presence of 0.3-1 microM epinephrine, however, theophylline dose-dependently increased the diastolic slope, the rate of spontaneous discharges and the force of contraction. The increase in tissue level of cyclic AMP (+288 +/- 69%) induced by 0.3 mM theophylline in the presence of epinephrine was much greater than the increase (+73 +/- 19%) in the absence of epinephrine. It is concluded that pacemaker activity in human atrial fibers is modulated by tissue levels of cyclic AMP and theophylline may induce atrial tachycardia through an increase in the diastolic slope and the rate of discharges of automatic atrial fibers.